BLUE RIDGE UROLOGICAL ASSOCIATES, P.C.
70 Medical Center Circle
Suite 208/212
Fishersville, VA 22939
Phone: 540-932/332-5926
PATIENT INFORMATION:
Last Name: _____________________________ First: _________________________ Middle: ______________
DOB: _____________________
Age: ___________
SSN: ______________________________________
Address: _____________________________________________________ City: _________________________
State: ______ Zip: _____________ Home Phone: _____________________ Cell Phone: ___________________
Email Address: _____________________________________________________
Marital Status: _____________
Spouse/Partner Name: _________________________________________
Emergency Contact: ________________________________ Phone: __________________________________
Family / Referring Doctor: ___________________________ Phone: ___________________________________
Were You Referred Today? YES _____ NO _____ BY ________________________________________________
What Pharmacy Do You Use? __________________________ Phone: __________________ Zip: ___________
Patient’s Employer: _________________________________________________________________________
Employer’s Address: ________________________________________ City: ____________________________
State: ______ Zip: ___________________ Work Phone: ___________________________________________
GUARANTOR INFORMATION: (Complete Only If Other Than Patient)
Name: __________________________________________________ Date of Birth: ______________________
Relationship to Patient: ________________________ Phone: ________________________________________
Address: _____________________________ City: ______________________ State: _______ Zip: __________
REASON FOR YOUR VISIT:________________________________________________________
ALLERGIES: ___________________________________________________________________
CURRENT MEDICATIONS: (PLEASE INCLUDE STRENGTH AND HOW MEDICATION IS TAKEN)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
ARE YOU TAKING BLOOD THINNERS SUCH AS ASPIRIN, COUMADIN/WARFAIN, NSAIDS,
PLAVIX, PRADAXA, ETC?
YES NO LIST _____________________________________
HAVE YOU HAD A HEART ATTACK IN THE LAST YEAR?
YES
NO
If YES, date of heart attack _________________ Are you taking aspirin or blood thinner as a
result? YES NO
HAVE YOU HAD A COLONOSCOPY? YES
ARE YOU DIABETIC? YES
NO
DATE:______________________________
NO If Yes, date you were diagnosed:_____________________
HAVE YOU BEEN DIAGNOSED WITH DIABETIC NEUROPATHY? YES
DO YOU HAVE HIGH BLOOD PRESSURE? YES
NO
NO If Yes, date diagnosed:______________
HAVE YOU RECEIVED THE PNEUMOCOCCAL VACCINATION? YES
NO
If YES, who administered it and when? ____________________________________________
SURGICAL HISTORY: (PLEASE LIST ALL SURGERIES AND DATES)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
PERSONAL MEDICAL HISTORY: (CIRCLE IF YOU HAVE HAD ANY OF THE FOLLOWING)
Anemia
Anxiety
Arthritis
Asthma
Blood Clots
Bronchitis
Cerebrovascular Accident
Constipation
COPD
Depression
Diabetes
Diverticulitis
Gallstones
GERD
Glaucoma
Heart Attack
Heart Disorder/Disease
Hepatitis/Liver Problems
High Blood Pressure
High Cholesterol
Kidney Stones
Migraines
Pacemaker
Pneumonia
Seizures
Shortness of Breath
Thyroid Disorder/Disease
Frequent Urination
PERSONAL MEDICAL HISTORY: (CONTINUED)
Cancer (If so, what type)
_________________________________________________________________________________________
List Any Other Medical Condition(s) ____________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Have You Ever Had Any Problems With Anesthesia? _______________________________________________
SOCIAL HISTORY: (Please Circle Correct Response)
Marital Status:
Married
Single
Divorced
Smoking Status: Current Every Day Smoker
Current Some Day Smoker
Former Smoker
Yes
Smokeless Tobacco:
Yes
Widowed
Yes
How many? ________
How many? ________
When did you quit? _________
Yes
Do You Drink Alcohol?
Separated
Annulled
Life Partner
No
No
No/Never a Smoker
No
Yes
Which type? Beer Wine Liquor How much? ______________
Not Anymore When did you quit? ________
Do You Use Recreational Drugs?
No
Never drank __________
Yes If Yes explain:_________________________________
How Many Caffeinated Drinks Do You Have Each Day?:
_______________________________________
Race:
Hispanic/Latino
White
Ethnicity: Hispanic/Latino
Black/African American
Yes
Have You Ever Had A Blood Transfusion?
Other: _______________
No
Yes
No
FAMILY HISTORY: (INCLUDE PARENTS, SIBLINGS, AND GRANDPARENTS ONLY)
CONDITION:
WHO?
Anemia
________________________________________________
Anxiety
________________________________________________
Arthritis
________________________________________________
Asthma
________________________________________________
Blood Clots
________________________________________________
Bronchitis
________________________________________________
Cerebrovascular Accident
________________________________________________
FAMILY HISTORY CONTINUED:
CONDITION:
WHO?
Constipation
________________________________________________
COPD
________________________________________________
Depression
________________________________________________
Diabetes
________________________________________________
Diverticulitis
________________________________________________
Gallstones
________________________________________________
GERD
________________________________________________
Glaucoma
________________________________________________
Heart Attack
________________________________________________
Heart Disorder/Disease
________________________________________________
Hepatitis/Liver Problems
________________________________________________
High Blood Pressure
________________________________________________
High Cholesterol
________________________________________________
Kidney Stones
________________________________________________
Migraines
________________________________________________
Pacemaker
________________________________________________
Pneumonia
________________________________________________
Seizures
________________________________________________
Shortness of Breath
________________________________________________
Thyroid Disorder/Disease
________________________________________________
Frequent Urination
________________________________________________
Cancer (If so, what type)
_______________________________________
________________________________________________
_______________________________________
________________________________________________
_______________________________________
________________________________________________
LIST ANY PERSON(S) THAT WE MAY SPEAK WITH CONCERNING YOUR MEDICAL RECORDS:
______________________________ Relationship/Phone No: ___________________________
______________________________ Relationship/Phone No: ___________________________
______________________________ Relationship/Phone No: ___________________________
______________________________ Relationship/Phone No: ___________________________
______________________________ Relationship/Phone No: ___________________________